Falls with No Loss of Consciousness

Differential Diagnosis

Common Diagnoses

  • Orthostatic Hypotension
  • Parkinson’s Disease
  • Iatrogenic (e.g. Phenothiazines, Hypoglycaemics, Tricyclics and Hypotensives)
  • Postural Instability (Osteoarthritis, Muscular Weakness and General Frailty)
  • Any Acute Illness (e.g. Sepsis, CVA)

Occasional Diagnoses

  • Peripheral Neuropathy (Various Causes)
  • Lack of Concentration (Tripping over Mats, etc.)
  • Visual Disturbance
  • Acute Alcohol Intoxication and Chronic Alcohol Misuse 
  • Cardiac Arrhythmias
  • Any Cause of Vertigo (e.g. Vestibular Neuritis, Ménière’s Disease) or Non-specific Dizziness (e.g. Anaemia)
  • Hypoglycaemic Episodes
  • Dementia

Rare Diagnoses

  • Hydrocephalus
  • Third Ventricular Tumour
  • Diabetic Autonomic Neuropathy
  • Aortic Stenosis
  • Painless (‘Silent’) Myocardial Infarction

Ready Reckoner

Key distinguishing features of the most common diagnoses

Orthostatic HypotensionParkinson’s DiseaseIatrogenicPostural InstabilityAcute Illnes
Joint StiffnessNoNoNoPossibleNo
On Standing upYesPossiblePossiblePossibleYes
ConfusedNoNoPossibleNoPossible
PolypharmacyPossiblePossiblePossibleNoNo
On Turning HeadNoNoNoNoPossible

Possible Investigations

Likely:Urinalysis, FBC.

Possible:TFT, U&E, B12 and folate, fasting glucose or HbA1c, serum electrophoresis, vitamin D, LFT, ECG (or 24 h ECG/event monitor).

Small Print:CT scan, echocardiography.

  • Urinalysis for glucose may reveal underlying diabetes: A major cause of autonomic or peripheral neuropathy – or evidence of UTI.
  • FBC: Anaemia will exacerbate any cause of postural hypotension, or may itself cause dizziness. Sepsis is suggested by a raised WCC. A high MCV may be a useful pointer to alcohol misuse, B12 or folate deficiency, or hypothyroidism.
  • TFT: Hypothyroidism is common in the elderly and develops insidiously.
  • Fasting glucose or HbA1c: To confirm or detect diabetes.
  • U&E, B12 and folate, serum electrophroresis: Renal failure, B12/folate deficiency or myeloma may cause a peripheral neuropathy.
  • Vitamin D: Deficiency may cause muscular weakness.
  • LFT: For evidence (γGT) of alcohol misuse.
  • ECG or 24 h ECG/event monitor is useful to identify an arrhythmia, conduction defect or MI.
  • CT scanning (e.g. for tumours or hydrocephalus) or echocardiography (for aortic stenosis) may be arranged by the specialist after referral.

Top Tips

  • Failure to observe the patient’s gait may mean that significant diagnoses, such as Parkinson’s disease, are missed.
  • Recurrent falls in the elderly are often caused by a combination of factors, such as failing vision, poor lighting and trip hazards at home. A home assessment may give valuable clues.
  • In the acute situation, management may depend more upon the ability of the patient to remain safely at home (e.g. social support) rather than the precise diagnosis.
  • Don’t underestimate the importance of what you prescribe in causing morbidity. Attempt to reduce polypharmacy and review therapy regularly.
  • Recurrent falls in the frail elderly are a real concern with the prospect of significant injury and recurrent admission. They can also be fiendishly difficult to pin down and resolve – so use your local multidisciplinary falls team if you have one.

Red Flags

  • In dealing with this problem, don’t forget to look for cause and effect – the aetiology of the falls and any significant injuries sustained.
  • Sudden onset of falls in the previously well elderly patient is likely to represent acute pathology – have a low threshold for investigation or admission.
  • Gradual onset of recurrent falls is often multifactorial in the elderly; in younger patients, specific underlying disease is more likely, so refer for investigation.
  • Evidence of injury (e.g. bruises or fractures) and multiple attendance slips from A&E department indicate either a very frail, vulnerable elderly person or significant underlying illness.
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